Reduction Mammaplasty for BreastRelated Symptoms
Policy Number: 7.01.21
Origination: 7/2005
Last Review: 7/2016
Next Review: 7/2017
Policy
Blue Cross and Blue Shield of Kansas City (Blue KC) will provide coverage for
reduction mammaplasty when the criteria shown below are met.
When Policy Topic is covered
Reduction mammaplasty may be considered medically necessary for the
treatment of macromastia when well-documented clinical symptoms are present.
One bullet from criteria #1 and one bullet from criteria #2 must be present to
indicate medical necessity:


Documentation of a minimum 6-week history of shoulder, neck, or back pain
related to macromastia that is not responsive to conservative therapy, such as
an appropriate support bra, exercises, heat/cold treatment, and appropriate
nonsteroidal anti-inflammatory agents/muscle relaxants.
Recurrent or chronic intertrigo between the pendulous breast and the chest
wall.
Criteria #1
 Removal of at least 500 grams per breast; OR
 The average grams of tissue removed per breast falls above the 22 nd
percentile, relative to the patient’s body surface area
Body Surface Calculator (Haycock Formula):
http://medicalpolicy.bluekc.com?Calculator=BS
AND one of the following:
Criteria #2
 Documentation of a minimum 6-week history of shoulder, neck, or back
pain related to macromastia that is not responsive to conservative
therapy, such as an appropriate support bra, exercises, heat/cold
treatment, and appropriate non-steroidal anti-inflammatory
agents/muscle relaxants; OR

Intertrigo between the pendulous breast and the chest wall
When Policy Topic is not covered
It should be noted that the emotional and psychosocial distress associated with
body appearance does not constitute a medical rationale for reduction
mammaplasty, and thus these indications would be considered cosmetic in
nature.
Reduction mammoplasty is considered cosmetic for all other indications not
meeting the above criteria.
Considerations
Body surface area and cutoff weight
of average breast tissue removed
BSA (m²) = 0.024265 x Height(cm)0.3964 x Weight(kg)0.5378
Schnur Sliding Scale
Body Surface
Area (m2)
Average grams of tissue per breast to be
removed
1.35
199
1.40
218
1.45
238
1.50
260
1.55
284
1.60
310
1.65
338
1.70
370
1.75
404
1.80
441
1.85
482
1.90
527
1.95
575
2.00
628
2.05
687
2.10
750
2.15
819
2.20
895
2.25
978
2.30
1068
2.35
1167
2.40
1275
2.45
1393
2.50
1522
2.55
1662
2.60
1806
2.65
1972
2.70
2154
2.75
2352
2.80
2568
2.85
2804
2.90
3061
2.95
3343
3.00
3650
3.05
3985
3.10
4351
3.15
4750
3.20
5186
3.25
5663
3.30
6182
3.35
6750
3.40
7369
3.45
8045
3.50
8783
3.55
9589
3.60
10468
3.65
11428
3.70
12476
3.75
13619
3.80
14867
3.85
16230
3.90
17717
3.95
19340
4.00
21112
4.05
23045
4.10
25156
4.15
27459
4.20
29972
4.25
32716
4.30
35710
4.35
38977
4.40
42543
4.45
46435
4.50
50682
4.55
55316
4.60
60374
4.65
65893
4.70
71915
4.75
78487
4.80
85658
Description of Procedure or Service
Populations
Individuals:
 With symptomatic
macromastia
Interventions
Interventions of
interest are:
 Reduction
mammaplasty
Comparators
Comparators of
interest are:
 Nonsurgical
treatment
Outcomes
Relevant outcomes
include:
 Symptoms
 Functional outcomes
Summary
Macromastia, or gigantomastia, is a condition that describes breast hyperplasia or
hypertrophy. Macromastia may result in clinical symptoms such as shoulder, neck,
or back pain, or recurrent intertrigo in the mammary folds. In addition,
macromastia may be associated with psychosocial or emotional disturbances
related to the large breast size. Reduction mammaplasty is a surgical procedure
designed to remove a variable proportion of breast tissue to address emotional
and psychosocial issues and/or relieve the associated clinical symptoms.
The evidence for reduction mammaplasty in individuals who have symptomatic
macromastia includes randomized controlled trials and case series. Relevant
outcomes are symptoms and functional outcomes. These studies indicate that
reduction mammaplasty is effective at decreasing breast-related symptoms such
as pain and discomfort. There is also evidence that functional limitations related to
breast hypertrophy are improved following reduction mammaplasty. These
outcomes are achieved with acceptable complication rates. Overall, reduction
mammaplasty in appropriately selected patients is associated with improvements
in several important health outcomes.
Background
Macromastia, or gigantomastia, is a condition that describes breast hyperplasia or
hypertrophy. Macromastia may result in clinical symptoms such as shoulder, neck,
or back pain, or recurrent intertrigo in the mammary folds. In addition,
macromastia may be associated with psychosocial or emotional disturbances
related to the large breast size. Reduction mammaplasty is a surgical procedure
designed to remove a variable proportion of breast tissue to address emotional
and psychosocial issues and/or relieve the associated clinical symptoms.
While the literature search identified many articles that discuss the surgical
technique of reduction mammaplasty and document that reduction mammaplasty
is associated with a relief of physical and psychosocial symptoms, 1-9 an important
issue is whether reduction mammaplasty is medically necessary or cosmetic in
nature. For some patients, the presence of medical indications is clear-cut, ie, a
clear documentation of recurrent intertrigo or ulceration secondary to shoulder
grooving. For some patients, the documentation differentiating between a
cosmetic and medically necessary procedure will be unclear. Criteria for medically
necessary reduction mammaplasty are not well-addressed in the published medical
literature.
Some policies regarding medical necessity of reduction mammaplasty are based
on the weight of removed breast tissue. The basis of weight criteria is not related
to the outcomes of surgery, but to surgeons retrospectively classifying cases as
cosmetic or medically necessary. In 1991, Schnur et al, at the request of thirdparty payers, developed a sliding scale.10 This scale was based on survey
responses of 92 of 200 solicited plastic surgeons, who reported the height, weight,
and amount of breast tissue removed from each breast from the last 15 to 20
reduction mammaplasties they had performed. Surgeons were also asked if the
procedures were performed for cosmetic or medically necessary reasons. The data
were then used to create a chart relating the body surface area and the cutoff
weight of breast tissue removed that differentiated cosmetic and medically
necessary procedures. Based on their estimates, those with breast tissue removed
weight above the 22nd percentile line likely had the procedure performed for
medical reasons, while those below the 5th percentile line likely had the procedure
performed for cosmetic reasons; those falling between the cutpoints had the
procedure formed for mixed reasons. See Appendix Table 1 for the Schnur Sliding
Scale.
In 1999, Schnur reviewed the experience of the sliding scale as a coverage
criterion and reported that, while many payers had adopted it, many had also
misused it.11 Schnur pointed out that if a payer used weight of resected tissue as a
coverage criterion, then if the weight fell below the 5th percentile line, the
reduction mammaplasty would be considered cosmetic; if above the 22nd
percentile line, it would be considered medically necessary; and if between these
cutpoints, it would be considered on a case-by-case basis. Schnur also questioned
the frequent requirement that a woman be within 20% of her ideal body weight.
While weight loss might relieve symptoms, durable weight loss is notoriously
difficult and may be unrealistic in many cases.
Rationale
This evidence review was originally created in 1995 and has been updated with
searches of the MEDLINE database. The most recent literature review was
performed for the period of October 2014 through January 20, 2016. The following
is a summary of the key findings to date.
Efficacy in Reducing Symptoms
Observational Studies
Singh and Losken (2012) reported on a systematic review of studies reporting
outcomes after reduction mammaplasty.12 The reviewers found reduction
mammaplasty improved functional outcomes including pain, breathing, sleep, and
headaches. Additional psychological outcomes noted included improvements in
self-esteem, sexual function, and quality of life (QOL).
In 2002, Kerrigan et al published the results of the BRAVO (Breast Reduction:
Assessment of Value and Outcomes) study, a registry of 179 women undergoing
reduction mammaplasty.13 Women were asked to complete QOL questionnaires
and a physical symptom count both before and after surgery. The physical
symptom count focused on the number of symptoms present that were specific to
breast hypertrophy and included upper back pain, rashes, bra strap grooves, neck
pain, shoulder pain, numbness, and arm pain. In addition, the weight and volume
of resected tissue were recorded. Results were compared with a control group of
patients with breast hypertrophy, defined as size DD bra cup, and normal-sized
breasts, who were recruited from the general population. The authors proposed
that the presence of 2 physical symptoms might be an appropriate cutoff for
determining medical necessity for breast reduction. For example, while 71.6% of
the hypertrophic controls reported none or 1 symptom, only 12.4% of those
considered surgical candidates reported none or 1 symptom. This observation is
difficult to evaluate because the study did not report how surgical candidacy was
determined. The authors also reported that none of the traditional criteria for
determining medical necessity for breast reduction surgery (height, weight, body
mass index [BMI], bra cup size, or weight of resected breast tissue) had a
statistically significant relationship with outcome improvement. The authors
concluded that the determination of medical necessity should be based on
patients’ self-reported symptoms rather than more objectively measured criteria,
such as weight of excised breast tissue.
Randomized Controlled Trials
In 2008, Sabino Neto et al assessed functional capacity in which 100 patients,
ages 18 to 55 years, were randomized to reduction mammaplasty or waiting list
control.7 Forty-six patients from each group completed the study. At the onset of
the study and 6 months later, patients were assessed for functional capacity using
the Roland-Morris Disability Questionnaire (0=best performance, 24=worst
performance) and for pain using a visual analog scale (VAS). The reduction
mammaplasty group showed improvement in functional status, with an average
score of 5.9 preoperatively to 1.2 within 6 months postoperatively (p<0.001 for
pre-post comparison within the mammaplasty group) versus an unchanged
average score of 6.2 in the control group on the first and second evaluations.
Additionally, pain in the lower back region decreased on the VAS from an average
of 5.7 preoperatively to 1.3 postoperatively (p<0.001 for pre-post comparison
within the mammaplasty group) versus VAS average scores in the control group of
6.0 and 5.3 on the first and second evaluations, respectively (no significant
change).
Also in 2008, Saariniemi et al reported on QOL and pain in 82 patients who were
randomized to reduction mammaplasty or a nonoperative group and evaluated at
baseline and 6 months later.9 The authors reported that the mammaplasty group
had significant improvements in QOL, as measured by the Physical Component
Summary score of the 36-Item Short-Form Health Survey (SF-36; change, +9.7
vs +0.7, p<0.001), the Utility Index score (SF-6D; change, +17.5 vs +0.6), the
index score of QOL (SF-15D; change, +8.6 vs +0.06, p<0.001), and SF-36 Mental
Component Summary score (change, +7.8 vs -1.0, p<0.002). There were also
improvements in breast-related symptoms, as measured by the Finnish BreastAssociated Symptoms questionnaire score (-47.9 vs -3.5, p<0.001), and the
Finnish Pain Questionnaire score (-21.5 vs -1.0, p<0.001).
Iwuagwu et al reported on 73 patients randomized to receive reduction
mammaplasty within 6 weeks or after a 6-month waiting period to assess lung
function.8 All patients had symptoms related to macromastia. Postoperative lung
function correlated with the weight of breast tissue removed, but there were no
significant improvements in any lung function parameters for the mammaplasty
group compared with the control group.
Beraldo et al reported trial of 60 patients randomized to receive reduction
mammaplasty or no surgery.14 The study outcomes were sexual function and
depressive symptoms. At 6 months, Female Sexual Function Index scores were
higher in the reduction mammaplasty group (27.5 vs 22.5, p<0.001). Level of
depression, as measured by the Beck Depression Inventory, was lower in the
reduction mammaplasty group (7.2 vs 13.7, p=0.01). Analyses using categories of
sexual function or depression showed similar results.
Studies Reporting Complications
Thibaudeau et al (2010) conducted a systematic review to evaluate breastfeeding
after reduction mammaplasty.15 After a review of literature from 1950 through
December 2008, the authors concluded that reduction mammaplasty does not
reduce the ability to breastfeed. In women who had reduction mammaplasty,
breastfeeding rates were comparable in the first month postpartum to rates in the
general population in North America.
In 2011, Chen et al reported on a review of claims data to compare complication
rates after breast surgery in 2403 obese and 5597 nonobese patients. 16 Of these
patients, breast reduction was performed in 1939 (80.7%) in the study group and
3569 (63.8%) in the control group. Obese patients had significantly more claims
for complications within 30 days after breast reduction surgery than nonobese
patients (14.6% vs 1.7%, respectively, p<0.001). Complications included
inflammation, infection, pain, and seroma/hematoma development. Also in 2011,
Shermak et al reported on a review of claims data comparing complication rates
by age after breast reduction surgery in 1192 patients. 17 Infection occurred more
frequently in patients older than 50 years of age (odds ratio [OR], 2.7; p=0.003).
Additionally, women older than 50 years experienced more wound healing
problems (OR=1.6; p=0.09) and reoperative wound débridement (OR=5.1;
p=0.07). Other retrospective evaluations of large population datasets have
reported an increased incidence of perioperative and postoperative complications
with high BMI.18,19
Section Summary: Efficacy in Reducing Symptoms
Several randomized trials and observational studies have shown improvements in
several measures of function and QOL.
Ongoing and Unpublished Clinical Trials
A search of ClinicalTrials.gov in January 2016 did not identify any ongoing or
unpublished trials that would likely influence this review.
Summary of Evidence
The evidence for reduction mammaplasty in individuals who have symptomatic
macromastia includes randomized controlled trials and case series. Relevant
outcomes are symptoms and functional outcomes. These studies indicate that
reduction mammaplasty is effective at decreasing breast-related symptoms such
as pain and discomfort. There is also evidence that functional limitations related to
breast hypertrophy are improved following reduction mammaplasty. These
outcomes are achieved with acceptable complication rates. Overall, reduction
mammaplasty in appropriately selected patients is associated with improvements
in several important health outcomes.
Practice Guidelines and Position Statements
The American Society of Plastic Surgeons (ASPS) has issued practice guidelines
and a companion document on criteria for third-party payers for reduction
mammaplasty.20-22 ASPS indicates level I evidence has shown reduction
mammaplasty is effective in treating symptomatic breast hypertrophy, which “is
defined as a syndrome of persistent neck and shoulder pain, painful shoulder
grooving from brassiere straps, chronic intertriginous rash of the inframammary
fold, and frequent episodes of headache, backache, and neuropathies caused by
heavy breasts caused by an increase in the volume and weight of breast tissue
beyond normal proportions.” ASPS also indicates the volume or weight of breast
tissue resection should not be criteria for reduction mammaplasty. If 2 or more
symptoms are present all or most of the time, reduction mammaplasty is
appropriate.
U.S. Preventive Services Task Force Recommendations
Not applicable.
Medicare National Coverage
There is no national coverage determination (NCD). In the absence of an NCD,
coverage decisions are left to the discretion of local Medicare carriers.
References
1. Dabbah A, Lehman JA, Jr., Parker MG, et al. Reduction mammaplasty: an outcome analysis.
Annals of plastic surgery. Oct 1995;35(4):337-341. PMID 8585673
2. Schnur PL, Schnur DP, Petty PM, et al. Reduction mammaplasty: an outcome study. Plastic and
reconstructive surgery. Sep 1997;100(4):875-883. PMID 9290655
3. Hidalgo DA, Elliot LF, Palumbo S, et al. Current trends in breast reduction. Plastic and
reconstructive surgery. Sep 1999;104(3):806-815; quiz 816; discussion 817-808. PMID
10456536
4. Glatt BS, Sarwer DB, O'Hara DE, et al. A retrospective study of changes in physical symptoms
and body image after reduction mammaplasty. Plastic and reconstructive surgery. Jan
1999;103(1):76-82; discussion 83-75. PMID 9915166
5. Collins ED, Kerrigan CL, Kim M, et al. The effectiveness of surgical and nonsurgical
interventions in relieving the symptoms of macromastia. Plastic and reconstructive surgery. Apr
15 2002;109(5):1556-1566. PMID 11932597
6. Iwuagwu OC, Walker LG, Stanley PW, et al. Randomized clinical trial examining psychosocial
and quality of life benefits of bilateral breast reduction surgery. The British journal of surgery.
Mar 2006;93(3):291-294. PMID 16363021
7. Sabino Neto M, Dematte MF, Freire M, et al. Self-esteem and functional capacity outcomes
following reduction mammaplasty. Aesthetic surgery journal / the American Society for
Aesthetic Plastic surgery. Jul-Aug 2008;28(4):417-420. PMID 19083555
8. Iwuagwu OC, Platt AJ, Stanley PW, et al. Does reduction mammaplasty improve lung function
test in women with macromastia? Results of a randomized controlled trial. Plastic and
reconstructive surgery. Jul 2006;118(1):1-6; discussion 7. PMID 16816661
9. Saariniemi KM, Keranen UH, Salminen-Peltola PK, et al. Reduction mammaplasty is effective
treatment according to two quality of life instruments. A prospective randomised clinical trial.
Journal of plastic, reconstructive & aesthetic surgery : JPRAS. Dec 2008;61(12):1472-1478.
PMID 17983882
10. Schnur PL, Hoehn JG, Ilstrup DM, et al. Reduction mammaplasty: cosmetic or reconstructive
procedure? Annals of plastic surgery. Sep 1991;27(3):232-237. PMID 1952749
11. Schnur PL. Reduction mammaplasty-the schnur sliding scale revisited. Annals of plastic surgery.
Jan 1999;42(1):107-108. PMID 9972729
12. Singh KA, Losken A. Additional benefits of reduction mammaplasty: a systematic review of the
literature. Plastic and reconstructive surgery. Mar 2012;129(3):562-570. PMID 22090252
13. Kerrigan CL, Collins ED, Kim HM, et al. Reduction mammaplasty: defining medical necessity.
Medical decision making : an international journal of the Society for Medical Decision Making.
May-Jun 2002;22(3):208-217. PMID 12058778
14. Beraldo FN, Veiga DF, Veiga-Filho J, et al. Sexual function and depression outcomes among
breast hypertrophy patients undergoing reduction mammaplasty: a randomized controlled trial.
Annals of plastic surgery. Dec 19 2014. PMID 25536204
15. Thibaudeau S, Sinno H, Williams B. The effects of breast reduction on successful breastfeeding:
a systematic review. Journal of plastic, reconstructive & aesthetic surgery : JPRAS. Oct
2010;63(10):1688-1693. PMID 19692299
16. Chen CL, Shore AD, Johns R, et al. The impact of obesity on breast surgery complications.
Plastic and reconstructive surgery. Nov 2011;128(5):395e-402e. PMID 21666541
17. Shermak MA, Chang D, Buretta K, et al. Increasing age impairs outcomes in breast reduction
surgery. Plastic and reconstructive surgery. Dec 2011;128(6):1182-1187. PMID 22094737
18. Nelson JA, Fischer JP, Chung CU, et al. Obesity and early complications following reduction
mammaplasty: An analysis of 4545 patients from the 2005-2011 NSQIP datasets. J Plast Surg
Hand Surg. Oct 2014;48(5):334-339. PMID 24506446
19. Gust MJ, Smetona JT, Persing JS, et al. The impact of body mass index on reduction
mammaplasty: a multicenter analysis of 2492 patients. Aesthetic surgery journal / the
American Society for Aesthetic Plastic surgery. Nov 1 2013;33(8):1140-1147. PMID 24214951
20. American Society of Plastic Surgeons. Reduction Mammaplasty: ASPS Recommended Insurance
Coverage Criteria for Third-Party Payers. 2011;
http://www.plasticsurgery.org/Documents/medical-professionals/healthpolicy/insurance/Reduction_Mammaplasty_Coverage_Criteria.pdf
21. American Society of Plastic Surgeons. Evidence-based Clinical Practice Guideline: Reduction
Mammaplasty. 2011; http://www.plasticsurgery.org/Documents/medical-professionals/healthpolicy/evidencepractice/Reduction_Mammaplasty_Evidence_Based_Guideline%20%282%29%282%29.pdf
22. Kalliainen LK. ASPS Clinical Practice Guideline Summary on Reduction Mammaplasty. Plastic
and reconstructive surgery. Oct 2012;130(4):785-789. PMID 23018692s
Billing Coding/Physician Documentation Information
19318
Reduction mammoplasty
ICD-10 Codes
Hypertrophy of breast
Non-pressure chronic ulcer of skin of other sites limited to breakdown
of skin
M25.511- Pain in shoulder; code range
M25.519
M54.89Dorsalgia; code range
M54.9
N62
L98.491
Additional Policy Key Words
Reduction mammoplasty
Breast reduction
Policy Implementation/Update Information
7/1/05
New policy added to the Surgery section.
7/1/06
No policy statement changes
10/1/06 Policy statement revised to clarify which criteria are required for
determining medical necessity. Removed “impaired function or
movement” from the list of criteria. Minimum amount of grams
changed from 600 grams total to 500 grams per breast. Added the
Schnur Sliding Scale to the list of criteria.
7/1/07
No policy statement changes.
7/1/08
No policy statement changes.
7/1/09
No policy statement changes.
7/1/10
No policy statement changes.
7/1/11
No policy statement changes. Body Surface Area calculator corrected.
7/1/12
No policy statement changes.
7/1/13
No policy statement changes.
7/1/14
No policy statement changes.
7/1/15
No policy statement changes
7/1/16
No policy statement changes.
State and Federal mandates and health plan contract language, including specific
provisions/exclusions, take precedence over Medical Policy and must be considered first in
determining eligibility for coverage. The medical policies contained herein are for informational
purposes. The medical policies do not constitute medical advice or medical care. Treating health
care providers are independent contractors and are neither employees nor agents Blue KC and are
solely responsible for diagnosis, treatment and medical advice. No part of this publication may be
reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic,
photocopying, or otherwise, without permission from Blue KC.